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Episiotomy

Episiotomy incisions may be carried out to assist delivery.

An episiotomy is a straight cut through the muscle and connective tissue in the perineal area to enlarge the opening of the vagina. The decision to perform an episiotomy is usually made as the baby’s head begins to emerge.

It is generally done in one of two ways:

  • midline cut made from the vagina towards the anus or
  • mediolateral made from the vagina sloping out to one side

An episiotomy can be done under local anaesthetic although for a small episiotomy, this is not always necessary as the pressure of the baby’s head on the perineum can numb the feeling. Minor lacerations known as first-degree, are common and usually heal well.

The number of stitches required is related to the size and depth of the cut. The larger the incision, the longer it will take to heal, often causing tenderness, discomfort and swelling for days, sometimes weeks afterwards. Since the incision is made through both skin and muscle layers, careful repair of the wound afterwards can take as long as an hour, often requiring local anaesthetic. 

Repairing a midline cut can often be quicker as there is a natural division between the muscles making it a simpler process. Suturing is done with a special curved needle and if they are dissolvable stitches, they can be left to dissolve within a couple of weeks. It is advisable to check the wound daily for signs of possible infection and to make sure the stitches haven’t dropped out and become imbedded in the tissue.

Is an Episiotomy necessary?

The answer to this depends on circumstances and who you ask.
Episiotomies are not routine. They are usually carried out when there are signs of the baby becoming distressed, the birth needs to be hastened or in cases of forceps delivery. For some women, the appropriate use of episiotomy is important.

Medical professionals believe episiotomy reduces the chance of uncontrolled tearing of the perineal tissue that can be more difficult to repair. It is also believed that prolonged pushing can have a negative long-term impact on pelvic floor function and that shortening the second stage of labour is better for the baby. Though there are many arguments against episiotomy, there are always situations where an episiotomy is fully justified.

Problems arising from Episiotomy

The World Health Organisation recommends that episiotomy should only be necessary with 10 per cent of births and certainly no higher than 20 per cent. In some Australian hospitals rates are as high as 40 per cent and in the United Kingdom, the proportion is only marginally lower than this. Clearly, many are performed without necessity. Though there is no concrete evidence to back up the arguments against the procedure of episiotomy, the following thoughts are worth considering.

Episiotomy may cause:

  • unnecessary bleeding if performed too early as the tissue has not thinned enough
  • increased chance of further tearing the episiotomy incision
  • infection of stitches requiring antibiotics
  • Incontinence
  • Long-term discomfort during sexual intercourse
  • Pain, swelling, tenderness for days, even weeks afterwards
  • Excessive stress and pain far greater than that of superficial tearing

Certain birthing positions are thought to make episiotomy and tears less likely as they encourage maximum stretching of the perineum. These include positions used in active birthing methods such as being on hands and knees, squatting, upright and using a birth stool.

Other suggestions include perineal massage during the last two months, maintaining a good diet to promote the skin’s elasticity, practising pelvic floor exercises and timing during labour. The most common cause of tearing is not allowing time for the perineum to stretch. At this time, strong sensations encourage a desire to push the baby out, though timing is crucial to allow the surrounding tissue to stretch and thin in preparation. The doctor or midwife can help with hot packs.

Aftercare

The pain related to episiotomy and tearing is primarily from swelling and inflammation. Using icepacks can help. Arnica and Bach flower rescue remedy will also aid the healing process. The sting of urine passing over the sutured area can be minimised by slowly trickling a jug of warm water over the pubic area to dilute the urine as it is passed. Soaking in a salt or lavender bath can be soothing and using pads soaked in witchazel can be helpful. Rather than towel drying the area, a hair dryer can be useful.

If you are concerned about episiotomy, it is important to discuss this subject with your doctor or midwife well in advance.      




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